Hindawi Publishing Corporation

Psychiatry Journal
Volume 2014, Article ID 694565, 7 pages
http://dx.doi.org/10.1155/2014/694565

Research Article
Perceived Stigma and Associated Factors among People with
Schizophrenia at Amanuel Mental Specialized Hospital, Addis
Ababa, Ethiopia: A Cross-Sectional Institution Based Study

Berhanu Boru Bifftu and Berihun Assefa Dachew

College of Medicine and Health Science, Department of Nursing, Gondar University, P.O. Box 196, Gondar, Ethiopia

Correspondence should be addressed to Berhanu Boru Bifftu; berhanuboru@gmail.com

Received 18 February 2014; Revised 23 April 2014; Accepted 7 May 2014; Published 21 May 2014

Academic Editor: Richard W. Neufeld

Copyright 2014 B. B. Bifftu and B. A. Dachew. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. While effective treatments are available for people with schizophrenia, presence of perceived stigma prevents them
from accessing and receiving the help they need to get. Objectives. To assess the prevalence and associated factors of perceived stigma
among people with schizophrenia attending the Outpatient Department of Amanuel Mental Specialized Hospital, Addis Ababa,
Ethiopia. Methods. Institution based cross-sectional study design was conducted among 411 subjects using an Amharic version
of the perceived devaluation and discrimination scale. Single population proportion formula was used to calculate sample size.
Subjects were selected by systematic sampling techniques. Binary logistic regression and odds ratio with 95% confidence interval
were used to identify the association factors of outcome variables. Results. A total of 411 subjects participated in the study giving
a response rate of 97.4%. The prevalence of perceived stigma was found to be 83.5%. Education status (not able to read and write)
(AOR = 2.64, 95% CI: 1.118, 6.227), difficulties of adherence to antipsychotic drug (AOR = 4.49, 95% CI: 2.309, 8.732), and duration
of illness less than one year (AOR = 3.48, 95% CI: 2.238, 5.422) were factors associated with perceived stigma. Conclusion. Overall,
the prevalence of perceived stigma was found to be high. Education status (not able to read and write), difficulties of adherence
to antipsychotic medication, and duration of illness were factors associated with perceived stigma. Adherence to antipsychotic
medication particularly during the early stage of the illness and strengthening the educational status of the participants were
suggested in the clinical care setting.

1. Background was selected as the central focus of the World Psychiatric

Mental and behavioral disorders are estimated to account for
12% of the global burden of disease [1]. Globally, 450 million
people were estimated to be suffering from neuropsychiatric
conditions [2]. Of these conditions Schizophrenia is one of
the most chronic and disabling illnesses, which affects 24
million people worldwide [2, 3]. In Ethiopia, mental illness
is the leading noncommunicable disorder in terms of burden
with schizophrenia and depression included in the top ten
most burdensome conditions, out-ranking HIV/AIDS [4].
While effective treatment for mental disorders is avail-
able, barriers such as stigma against people with mental
disorders prevent them from accessing and receiving the
help they need to get and stay well [1]. One of the most
severely stigmatized mental disorders is schizophrenia, which
Associations global antistigma programme entitled Open
the Doors [5, 6].
Stigma is typically a social process, experienced or
anticipated and characterized by exclusion, rejection, and
blame or devaluation about a person or group [7]. Literature
reveals that stigma occurs at three different levels, namely,
the macro-, meso-, and microlevel. Institutional stigma refers
to the stigma that exists at system (macro) level and was
defined as the rules, policies, and procedures of private
and public entities in positions of power that restrict the
rights and opportunities of people with disabling conditions.
Public stigma occurs at the group (meso) level and can be
defined as the phenomenon of large social groups endorsing
stereotypes about and acting against a stigmatized group
[8].
2 Psychiatry Journal
Attitudes toward mental illness vary among individuals,
families, ethnicities, cultures, and countries. Cultural and
religious teachings often influence beliefs about the origins
and nature of the illness and shape attitudes towards the
mentally ill [9]. Microlevel stigma is the stigma existing at the
individual. Although the term mental illness stigma is often
used in a broad sense at microlevel, it can be divided into
perceived public stigma/stereotype awareness (participants
beliefs that in general people with mental illness are stig-
matized in society), personal stigma/stereotype agreement
(participants personal beliefs about mental illness), and self-
stigma or internalized stigma occurs when an individual
with mental illness identifies themselves with the stigmatized
group and applies corresponding stereotypes and prejudices
to the self [10, 11].
Although the reasons for stigmatization are not con-
sistent across communities or cultures, perceived stigma
by individuals living with mental illness is associated with
different consequences. Different literature reported that
perceived stigma affects many domains of the lives of people
with schizophrenia such as impacts on self-esteem [12, 13],
recovery from the illness, social relationships [14], treatment
adherence, willingness to seek help [15], persistent suffering,
disability and economic loss [6], and difficulties of accessing
housing and employment [16]. These impacts can worsen a
clients mental illness and consequently result in involvement
in the criminal justice system rather than being treated by the
mental health services [17].
Many studies from the Western world have reported on
stigmatization of people with mental illnesses and its negative
consequences, but few studies have addressed the issue in
developing societies. The few studies conducted in Africa
reported that stigma regarding mental illness is widespread.
A representative survey based on a questionnaire developed
for the World Psychiatric Associations Programme to Reduce
Stigma and Discrimination because of Schizophrenia was
conducted in three Yoruba-speaking communities in Nigeria
and the result found predominantly negative views on mental
illness across all study subjects [18]. Similar finding was
reported from Ghana [19].
In Ethiopia studies revealed that there are widespread
beliefs that severe mental illnesses are due to demon pos-
sessions, bewitchment by evil spirits, ancestors spirits, or
the evil eyes. As a result, affected individuals and/or their
families often seek help from religious and traditional healers
rather than health facilities [4]. However, the available studies
from Western and some African countries demonstrated high
perceived stigma; in Ethiopia there is no previous study that
reported on perceived stigma specifically among people with
schizophrenia. The only reported study concerning perceived
stigma was carried out among family members of individuals
with schizophrenia and major affective disorders in rural
Ethiopia [20] and internalized stigma among people with
schizophrenia [21]. Therefore, in Ethiopia, with its cultural
diversity and mix of rural and urban environment, there is
a need to understand the stigma perceived by people with
schizophrenia. So the aim of this study was to assess the
prevalence of perceived stigma and associated factors among
individuals with schizophrenia in Ethiopia.
2. Methods
2.1. Study Design. Institution based cross-sectional study
design was used.
2.2. Study Area and Period. The study was conducted at
Amanuel Mental Specialized Hospital (AMSH) from March
1 to 30, 2012. AMSH was established in 1930 and is situated in
Addis Ababa, the capital city of Ethiopia. It is the only mental
health hospital in the country. At the beginning the hospital
was established to protect royal families from mentally ill
people, not to care for patients with mental illnesses. The
hospital has a total of 300 beds of which 277 are for inpatients
and 23 are Emergency beds; there is also a large out-patient
service, with around 115,000 visiting Outpatients Department
each year.
2.3. Participants. Participants of this study were individuals
with schizophrenia receiving follow-up care at the outpatient
department of Amanuel Mental Health Specialized Hospital.
Single population proportion formula (with 5% margin of
error, 95% confidence level, and 50% proportion) was used to
calculate sample size, and it was found to be 422 (including
10% nonresponse rate). The total number of patients who
were on follow up care for the last 12 months was taken
from patient records and then the average number of patients
per day was calculated and participants were selected by
systematic random sampling technique. All were consenting
individuals with a clinical diagnosis of schizophrenia coming
for follow-up, age greater than or equal to 18 years. Individuals
with schizophrenia who were unable to speak, hear and have
no insight were excluded from the study.
2.4. Instrument. The perceived stigma was measured by using
the perceived devaluation and discrimination scale (PDD).
The PDD is a 12-item tool which measures the extent to
which a person believes that most people will devalue or
discriminate against someone with a mental illness. PDD
was measured on a 4-point Likert scale with possible scores
ranging from 1 to 4 agreement scale (1 = strongly disagree, 2
= disagree, 3 = agree, and 4 = strongly agree), so that a higher
score indicates a higher level of perceived stigma. This scale
has been widely used across the world including Africa [19]
and has excellent psychometric properties [22]. Items 1, 2, 3,
4, 8, and 10 were reverse-scored.
The questionnaires were translated into Amharic lan-
guage by an Amharic speaking linguist. The back-translations
were performed by a psychiatrist into English and then a
consensus version was developed in a group discussion by
involving another psychiatrist and one Amharic speaking
linguist. This was compared with the original version and
confirmed to be satisfactory for use. In this study, PDD
had an internal consistence of Cronbachs alpha for the total
score was 0.79. The questionnaires were tested on 21 patients
to make it easier for the participants to understand and
complete.
The prevalence of high perceived stigma was defined as
an item mean score of 2.5 or higher on mean aggregated scale
Psychiatry Journal 3

score (this criterion represented the midpoint on the 14- Table 1: Sociodemographic characteristics of participants ( = 411)
item scale) on PDD scales. Then perceived stigma scores were at Amanuel Mental Specialized Hospital, 2012.
dichotomized as those participants scoring greater than or
Characteristics Number Percent
equal to the mean score of 2.5 on PDD scales as having high
perceived stigma and those scoring below the mean score as Sex
having low perceived stigma. Male 302 73.5
Furthermore, we asked two questions on antipsychotic Female 109 26.5
medication adherence and difficulties of patients adherence Age
to their clinic appointments (follow-up). The antipsychotic 1824 84 20.4
medication adherence question asked about history of non- 2534 162 39.4
adherence with antipsychotic medications and whether the 3544 114 27.7
nonadherence behavior was linked to stigma with yes/no 44 51 12.4
response. Specifically, we asked, have you ever discontinued Educational status
your antipsychotic medication because of fear of perceived
Cannot read and write 40 9.5
stigma associated with your mental illness? Have you ever
discontinued your clinic appointments (follow-up) because Primary 289 70.3
of fear of perceived stigma associated with your mental Secondary and above 52 20
illness? Religion
Muslim 91 22.1
2.5. Data Collection and Analysis. Data were collected by Orthodox 240 58.4
face-to-face interview using a semistructured questionnaire Protestant 67 16.3
with the Amharic version of the sociodemographic, clinical Catholic 13 3.2
factors, and perceived devaluation and discrimination ques- Marital status
tionnaires. Married 72 17.5
Data were coded and entered into EPI info version Single 286 69.6
3.5.3 statistical software and then exported to SPSS windows Divorced/widowed 53 12.8
version 16 program for analysis. Descriptive statistics (fre- Ethnicity
quencies, tables, percentages, means, and standard deviation)
Oromo 132 32.1
were used for the sociodemographic and clinical variables
Amhara 146 35.6
including individuals response items to PDD. Binary logistic
regression and odds ratio with 95% confidence interval were Gurage 98 23.8
used to identify the associated factors of outcome variable. Tigre 35 8.5
A significance level of 0.05 was taken as cut-off value for all Employment
statistical significance tests. Unemployed 257 62.5
Employed 154 37.5
2.6. Ethical Consideration. The study proposal was initially Residence
approved by the ethical review board of The University of Rural 89 21.7
Gondar and Amanuel Mental Specialized Hospital. A formal Urban 322 78.3
letter of permission was obtained from the hospital and Living arrangement
submitted to the respective Outpatient Department. The Family 360 87.6
information about the study was given to the participants. Alone 51 12.4
Verbal then written informed consent was sought for each
participant who agreed to participate in the study and fulfilled
the inclusions criteria. Only anonymous data were collected
in private rooms. marital status. One hundred and six (35.5%) of the partici-
pants were Amhara in Ethnicity. Out of 411 participants, 257
(62.5%) were unemployed, 322 (78.3%) were living in urban
3. Results areas, and 360 (87.6%) were living with their family (Table 1).
A total of 411 participants participated in this study with a
97.4% response rate. One of the participants failed to complete 3.2. Clinical Characteristics. Regarding the clinical character-
the interview because of the illness and nine questions were istics of participants, 117 (28.5%) were treated for 25 years,
not fulfilled properly. 287 (69.8%) had difficulties of attending clinic (follow-up),
and 64 (15.6%) had difficulties of adherence to antipsychotic
3.1. Sociodemographic Characteristics. The majority of the medication (Table 2).
participants were males 302 (73.5%). The mean ages of the
participants were 33.249.73 years. Two hundred and eighty- 3.3. Prevalence of Perceived Stigma. Overall, the prevalence of
nine (70.3%) of the participants were primary educated, 240 perceived stigma was found to be 83.5%. Regarding the pro-
(58.4%) were Orthodox, and 286 (69.6%) were single in portion of perceived stigma toward each item, the majority
4 Psychiatry Journal

Table 2: Distribution of participants ( = 411) by clinical studies from 1994 to 2011 also reported on average 64.5% of
characteristics at Amanuel Mental Specialized Hospital, 2012. participants perceived stigma [23].
This variation may be due to shared social percep-
Characteristics Frequency Percent
tion toward mental illness. A previous study relatives of
Duration of the treatment (in years) schizophrenia and affective disorder revealed that 75% of
1 101 24.5 respondents had perceived stigma in Ethiopia and since the
25 117 28.5 study subjects were drawn from these societies, they may
610 90 21.9 share the societys perception about mental illness stigma
[20]. This relationship indicates or supports the evidence of
11 103 25.1
relation between public stigma toward mental illness and
Duration of illness (in years) perceived stigma. This variation could be also due to the
1 204 49.6 differences in sample size, the population surveyed in the
25 78 19 setting, method of data collection, and lack of antistigma
610 45 10.9 interventions program in the study area.
11 84 20.5 Even if the ways in which the respondents experience
Follow-up adherence to clinic of perceived stigma toward each item was different from
appointment the study done in Ghana using the same tool because of
287 69.8
differences in the culture, setting, and other factors, there are
Yes
also a number of similarities reported. For example, 85.7%
No 124 30.2
of Ghanaian participants agreed with the item opinions of
Difficulty of adherence to antipsychotic a mentally ill person were taken less seriously compared to
drug 81% in this study and 77.2% of the participants agreed with
Yes 64 15.6 the item most employers would pass over an application
No 347 84.4 of a former mental patient in favour of another applicant
compared to 76.1% in this study [19].
Regarding the associated factors, those patients who
cannot read and write were more than two times (AOR =
(362) (88.07%) of the participants agreed with the item most 2.64, 95% CI: 1.118, 6.227) more likely to develop perceived
people think that a person who has been hospitalized for stigma than those patients who had educational status of
mental illness is dangerous and unpredictable (Table 3). secondary level and above. These results were consistent with
the previous study [12, 2426]. This is due to the fact that
3.4. Factors Associated with Perceived Stigma. From the bivar- those patients who cannot read and write may have poor
iate analysis, educational statuses, employment, residence, coping strategies to perceived stigma.
duration of illness, and difficulties of adherence to antipsy- From clinical variables those patients who had difficulties
chotic medication were factors associated with perceived of adherence to their antipsychotic medication were more
stigma in bivariate analyses and entered into multivariate than four times (AOR = 4.49, 95% CI: 2.309, 8.732) more
analysis. likely to experience perceived stigma than those patients who
On the other hand, age, sex, ethnicity, marital status, adhere to their medication. These results were consistent
religion, difficulties of adherence to clinic (follow-up), and with the meta-analysis carried out among one hundred and
living arrangement were not associated and were excluded twenty-seven studies in Europe [15, 27, 28]. This may be
from further analysis. due to fear of stigma and rejection which could prolong
From the multivariate analysis, education status (not the duration of help seeking and reduce the likelihood
able to read and write) (AOR = 2.64, 95% CI: 1.118, 6.227), of adherence to treatment. This may in turn result in an
difficulties of adherence to antipsychotic medication (AOR = increased risk of socially unacceptable violent behavior which
4.49, 95% CI: 2.309, 8.732), and duration of illness 1 year creates stigma.
(AOR = 3.48, 95% CI: 2.238, 5.422) were factors statistically Those patients who had less than or equal to one year
significant with perceived stigma (Table 4). duration of illness had more than three times (AOR = 3.48,
95% CI: 2.238, 5.422) perceived stigma than those patients
who had greater than one year duration of their illness.
4. Discussion These results were consistent with the previous studies in
India and Europe [22, 23, 29]. This may be due to the
The aim of this study was to assess the prevalence of presence of socially unacceptable behavior seen predom-
perceived stigma and associated factors among people with inantly during the acute phase of the illness. Behaviours
schizophrenia at Amanuel Mental Specialized Hospital. This such as hallucinations, delusions, and suspicion were found
study shows that overall the prevalence of perceived stigma to be very distressing and associated with the creation of
was found to be 83.5%. This study was higher when compared stigma. Another possible reason may be that since perceived
with the cross-sectional study carried out across 14 European stigma was the result of perception of public stigma, through
countries using the same tool. That study reported 69.4% [22] time, the patient may develop stigma resistance through
and a systematic review of studies including 54 published experience.
Psychiatry Journal 5

Table 3: Proportion of perceived stigma response of participants ( = 411) to each item at Amanuel Mental Specialized Hospital, 2012.

Items Strongly disagree Disagree agree Strongly agree

1 Most people would be close friends with a person who once had 22 267 116 6
severe mental illness.
2 Most people believe that a person who has severe mental illness is just 23 280 106 2
as intelligent as anyone else.
3 Most people believe that a person who has been treated for severe 12 246 151 2
mental illness is just as trustworthy as anyone else.
4 Most people would accept a person who has had severe mental illness 24 297 81 9
as a teacher in a school.
5 Most people believe that receiving treatment for severe mental illness 3 101 291 16
is a sign of personal failure.
Most people will not hire a person who has been hospitalized for
6 severe mental illness to take care of their children, even if he or she 3 174 214 20
had been well for some time.
7 Most people think less of a person who has been treated for severe 16 62 288 45
mental illness.
8 Most employers will hire a qualified person even if he or she has been 18 161 227 5
treated for severe mental illness.
9 Most employers would prefer to hire someone who does not have a 5 93 298 15
history of severe mental illness.
10 Most people I know would treat a person who has been treated for 9 157 239 6
severe mental illness the same way they treat everyone else.
11 Most young women would be reluctant to date a man who has been 37 358 12 4
treated for severe mental illness.
12 Most people think that a person who has been hospitalized for severe 3 46 346 16
mental illness is dangerous and unpredictable.

Table 4: Factors associated with perceived stigma (bivariate and multivariate) analysis, at Amanuel Mental Specialized Hospital, 2012.

Perceived stigma
Explanatory variables COR (95% CI) AOR (95% CI)
High Low
Education
Not able to read and write 27 13 2.93 (1.325, 6.488) 2.64 (1.118, 6.227)
Primary 143 146 1.38 (0.842, 2.271)
Secondary and above 34 48 1 1
Employment
Unemployed 135 122 1.36 (1.213, 4.036)
Employed 69 85 1
Residence
Rural 51 38 1.48 (1.323, 5.38)
Urban 153 169 1 1
Difficulty of adherence to antipsychotic medication
Yes 43 21 2.37 (1.347, 4.153) 4.49 (2.309, 8.732)
No 161 186 1 1
Duration of illness
>1 year 81 126 1 1
1 year 131 73 2.79 (1.872, 4.164) 3.48 (2.238, 5.422)
Note: not statistically significant using forward stepwise regression methods. Hosmer and Lemeshow test was 0.191.

4.1. Strength of the Study. This study is the first of its kind
in Ethiopia to show perceived stigma among people with
schizophrenia using a standard tool.
4.2. Limitations of the Study. The lack of published lit-
erature in Ethiopia limits the comparison (discussion)
of the findings. Recall and response biases might have
occurred when completing the questionnaire. In addition,
some of the independent variables were assessed with
single questions, for example, treatment adherence and
difficulties of follow-up adherence to their clinic appoin-
tments.
6 Psychiatry Journal
5. Conclusion
Overall, the prevalence of perceived stigma was found to
be high among the study participants. Lower educational
status, difficulties of adherence to antipsychotic medication,
and less than or equal to one year duration of illness were
factors associated with perceived stigma. These findings add
important evidence to the existing scant study in Sub-Saharan
Africa and other developing countries on the psychosocial
aspect of individual with schizophrenia as perceived stigma is
an important area to improve patients adherence to antipsy-
chotic medication. Therefore stigma focused intervention
such as adherence to antipsychotic medication particularly
during the early stage of the illness and strengthening the
educational status of the participants were suggested in the
clinical care setting. Additional researches with qualitative
and quantitative study methods are also suggested, in order
to explore the relation of sociodemographic and perceived
stigma.
Disclosure
Berihun Assefa Dachew is the coauthor of the paper.
Conflict of Interests
The authors declare no competing interests.
Authors Contribution
Berhanu Boru carried out the paper from its conception,
analysis, and interpretation of data and drafted the paper.
Berihun Assefa participated in data analysis, interpretation,
and review of the paper. Both authors read and approved the
final draft of the paper.
Funding
The fund of this paper was covered by the University of
Gondar College of Medicine and Health Science. Funder had
no role in study design, data collection, analysis, and decision
to publish. The corresponding author had full access to all the
data in the study and had final responsibility for the decision
to prepare the paper and submit it for publication.
Acknowledgments
Authors gratitude goes to the University of Gondar, Research
and community service core process for financial support.
They would like to thank the study subjects for their willing-
ness to participate in the study. They would also like to extend
their gratitude to Dr. Fesseha Zewude (Psychiatrist) for his
guidance by reviewing the paper, Abrham Zeleke (MPH) for
his statistical and methodological advice, and Wendy Corbin
who provide important comments by editing the language of
the paper. Last but not least our heartfelt thanks go to the
supervisors and data collectors for their admirable endeavor
during the data collection.
References
[1] Worlg Health Organization, The World Health Report, Approach
to Mental Health, WHO, Geneva, Switherland, 2001.
[2] World Health Organization, The World Health Report, Approach
to Mental Health, WHO, Geneva, Switherlan, 2002.
[3] J. G. Cesrnansky, Schizophrenia and relapse prevention, The
American Journal of Nursing, vol. 102, no. 7, pp. 1622, 2002.
[4] Health FDROEMO, National Mental Health Strategy 2012/13
2015/16, Federal Democratic Republic of Ethiopia Ministry of
Health, Addis Ababa, Ethiopia, 2012.
[5] S. M. Razali, Prevention of relapse and interventions for
enhancing medication adherence in schizophrenia: an East
Asian perspective, Asia-Pacific Psychiatry, vol. 2, no. 2, pp. 68
76, 2010.
[6] I. D. Base, Statistics by Country for Schizophrenia, US Census
Bureau, 2004.
[7] E. Goffman, Notes on the Management of a Spoiled Identity,
Prentice-Hall, Englewood Cliffs, NJ, USA, 1963.
[8] P. Werner, A. Aviv, and Y. Barak, Self-stigma, self-esteem and
age in persons with schizophrenia, International Psychogeri-
atrics, vol. 20, no. 1, pp. 174187, 2008.
[9] J. A. Nieuwsma, C. M. Pepper, D. J. Maack, and D. G. Birgenheir,
Indigenous perspectives on depression in rural regions of India
and the United States, Transcultural Psychiatry, vol. 48, no. 5,
pp. 539568, 2011.
[10] P. W. Corrigan, A. Kerr, and L. Knudsen, The stigma of mental
illness: explanatory models and methods for change, Applied
and Preventive Psychology, vol. 11, no. 3, pp. 179190, 2005.
[11] K. M. Griffiths, H. Christensen, A. F. Jorm, K. Evans, and C.
Groves, Effect of web-based depression literacy and cognitive-
behavioural therapy interventions on stigmatising attitudes
to depression: randomised controlled trial, British Journal of
Psychiatry, vol. 185, pp. 342349, 2004.
[12] J. B. Ritsher and J. C. Phelan, Internalized stigma predicts
erosion of morale among psychiatric outpatients, Psychiatry
Research, vol. 129, no. 3, pp. 257265, 2004.
[13] P. W. Corrigan, A. C. Watson, and L. Barr, The self-stigma of
mental illness: Implications for self-esteem and self-efficacy,
Journal of Social and Clinical Psychology, vol. 25, no. 8, pp. 875
884, 2009.
[14] P. T. Yanos, D. Roe, K. Markus, and P. H. Lysaker, Pathways
between internalized stigma and outcomes related to recovery
in schizophrenia spectrum disorders, Psychiatric Services, vol.
59, no. 12, pp. 14371442, 2008.
[15] D. L. Vogel, N. G. Wade, and A. H. Hackler, Perceived public
stigma and the willingness to seek counseling: the mediating
roles of self-stigma and attitudes toward counseling, Journal of
Counseling Psychology, vol. 54, no. 1, pp. 4050, 2007.
[16] H. Stuart, Mental illness and employment discrimination,
Current Opinion in Psychiatry, vol. 19, no. 5, pp. 522526, 2006.
[17] B. G. Link, E. L. Struening, S. Neese-Todd, S. Asmussen, and
J. C. Phelan, The consequences of stigma for the self-esteem of
people with mental illnesses, Psychiatric Services, vol. 52, no. 12,
pp. 16211626, 2001.
[18] J. Alonso, A. Buron, R. Bruffaerts et al., Association of per-
ceived stigma and mood and anxiety disorders: results from the
World Mental Health Surveys, Acta Psychiatrica Scandinavica,
vol. 118, no. 4, pp. 305314, 2008.
[19] A. Barke, S. Nyarko, and D. Klecha, The stigma of mental
illness in Southern Ghana: attitudes of the urban population and
Psychiatry Journal 7

patients views, Social Psychiatry and Psychiatric Epidemiology,

vol. 46, no. 11, pp. 11911202, 2011.
[20] T. Shibre, A. Negash, G. Kullgren et al., Perception of stigma
among family members of individuals with schizophrenia and
major affective disorders in rural Ethiopia, Social Psychiatry
and Psychiatric Epidemiology, vol. 36, no. 6, pp. 299303, 2001.
[21] T. S. Dereje Assefa, L. Asher, and A. Fekadu, Internalized
stigma among patients with schizophrenia in Ethiopia, BMC
Psychiatry, vol. 12, article 239, 2012.
[22] E. Brohan, R. Elgie, N. Sartorius, and G. Thornicroft, Self-
stigma, empowerment and perceived discrimination among
people with schizophrenia in 14 European countries: the
GAMIAN-Europe study, Schizophrenia Research, vol. 122, no.
1-3, pp. 232238, 2010.
[23] G. Gerlinger, M. Hauser, M. de Hert, K. Lacluyse, M. Wampers,
and C. U. Correll, Personal stigma in schizophrenia spectrum
disorders: a systematic review of prevalence rates, correlates,
impact and interventions, World Psychiatry, vol. 12, pp. 155164,
2013.
[24] F. B. Dickerson, J. Sommerville, A. E. Origoni, N. B. Ringel,
and F. Parente, Experiences of stigma among outpatients with
schizophrenia, Schizophrenia Bulletin, vol. 28, no. 1, pp. 143152,
2002.
[25] S. Lee, M. T. Y. Lee, M. Y. L. Chiu, and A. Kleinman, Experience
of social stigma by people with schizophrenia in Hong Kong,
British Journal of Psychiatry, vol. 186, pp. 153157, 2005.
[26] I. F. Brockington, P. Hall, J. Levings, and C. Murphy, The
communitys tolerance of the mentally ill, British Journal of
Psychiatry, vol. 162, pp. 9399, 1993.
[27] R. Thara and T. N. Srinivasan, How stigmatising is schizophre-
nia in India? International Journal of Social Psychiatry, vol. 46,
no. 2, pp. 135141, 2000.
[28] I. Sibitz, A. Unger, A. Woppmann, T. Zidek, and M. Amering,
Stigma resistance in patients with schizophrenia, Schizophre-
nia Bulletin, vol. 37, no. 2, pp. 316323, 2009.
[29] P. T. Yanos, D. Roe, and P. H. Lysaker, The impact of illness
identity on recovery from severe mental illness, American
Journal of Psychiatric Rehabilitation, vol. 13, no. 2, pp. 7393,
2010.

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Disease Markers
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